Rapid Versus Standard Recovery Protocol Is Associated With Improved Recovery of Range of Motion 12 Weeks After Total Knee Arthroplasty

Abstract

Introduction: With the increasing demand for total knee arthroplasty (TKA), rapid recovery protocols (RRPs) have been introduced to reduce costs and the length of stay (LOS). Little is known about the effects of RRPs on postoperative knee range of motion (ROM). Methods: We reviewed the medical charts of 323 patients who underwent primary TKA performed by a single orthopaedic surgeon at a university-based orthopaedic tertiary care safety net practice. Of the 323 patients, 129 were treated with a standard recovery protocol (SRP) between January 1, 2012, and December 10, 2013, and 194 with a RRP beginning December 11, 2013. Knee ROM was assessed at the preoperative visit and at scheduled postoperative visits for up to 1 year. Differences in mean LOS between the groups were compared using a Poisson regression with and without adjustment for covariates. Repeated measures analysis of covariance was used to evaluate the effects of recovery protocol, time, and the interaction of recovery protocol by time on flexion and flexion contracture. The probability of achieving flexion ≥120° and having a flexion contracture ≥10° was estimated using the SAS/STAT GLIMMIX procedure with a binary distribution and a logit link. Results: The mean LOS for the RRP and SRP groups was 0.8 and 2.5 days, respectively. RRP was associated with greater flexion at 2, 6, and 12 weeks and a higher probability of attaining flexion ≥120° at 6 and 12 weeks. Patients receiving a RRP had less severe flexion contracture and a lower probability of flexion contracture ≥10° at 2, 6, and 12 weeks. Discussion: During the first 12 weeks after TKA, patients who received a RRP had a markedly greater ROM than patients who received a SRP, suggesting that RRP may allow patients to do a greater variety of activities of daily living during the first 3 postoperative months while reducing health care costs. Level of Evidence: Level III

Outcomes of an Institutional Rapid Recovery Protocol for Total Joint Arthroplasty at a Safety Net Hospital

“…Several studies have now demonstrated the safety, efficacy, and cost-saving potential of RRPs for TJA in select patient cohorts and hospital systems. 7 8 9 10 11 12 , 22 - 24 Limited literature exists, however, regarding the utility of implementing a RRP in more marginalized patient populations and at resource-limited facilities. This study demonstrates that an institutional RRP can be successfully implemented at a safety net hospital with reduced LOS while still achieving fewer complications, readmissions, ED visits, and revision surgeries.…”

“… 7 8 9 10 Other studies have demonstrated that RRPs can be associated with reduced complication rates, improved functional outcomes, and improved range of motion after TKA. 11 , 12 Moreover, because these protocols have been associated with lower costs and increased discharge home versus skilled nursing facilities, 13 RRPs could be particularly valuable to safety net county hospitals where resources are limited and access to care is a particular challenge.…”

PASSED: Calculate Power and Sample Size for Two Sample Tests

“…LOS, or other count measurements important to the research study, can be modeled using a Poisson distribution. Plessl et al (2020) used a Poisson framework to compare LOS for those who were treated with rapid recovery protocols versus standard recovery protocols after total knee arthroplasty. This example can be expanded to the general case as follows.…”

“…Moreover, researchers often work with response variables that can take the form of a variety of distributions. For example, the proportion of thromboembolism after surgery in different treatment groups can be modeled using the binomial distribution or length of inpatient stay after an orthopedic procedure can be modeled using the Poisson distribution (Plessl et al, 2020). Some of the R packages or functions are designed to calculate the power and sample size for the variables following a certain distribution.…”

Effect of combined hip and knee exercises on rehabilitation after total knee arthroplasty: A prospective randomized trial

“…[8][9][10] Because these factors are coupled with mechanical injury of the quadriceps femoris caused by the surgical incision from TKA, the focus of traditional rehabilitation treatment is on recovery of the quadriceps femoris. [11,12] In recent years, there has been increasing evidence that a decrease in muscle strength around the hip joint may increase the load of the knee joint and aggravate the progression of OA. [13][14][15] Some scholars proposed that weakness of hip muscles is a potential cause of the increased load on the medial intercompartment of the tibial-femoral joint.…”